Offerings and acceptances. Technique and therapeutic action

This paper presents several proposal about clinical psychoanalysis. One proposal suggests that an analyst's essential offering is a non-hierarchical partnership in discovering. Another implies that a valuable goal of psychoanalytic work is to acquire the adaptive tool of "insighting," an acquisition that is promoted by the structure of the partnership. The paper contains arguments that support the proposals, as well as an extended clinical anecdote that illustrates them.

Differentiation and integration

The purpose of this paper is to propose a clinical approach to coordinating the psychoanalytic process with the developmental process in treating children. The paper is constructed as a dialogue between the spirit of Anna Freud and myself; a vignette brings together the principal traditional features Ms. Freud understood as "psychoanalytic" with her innovative propositions about the "developmental."

Quantitation of metal isotope ratios by laser desorption time-of-flight mass spectrometry

Laser desorption time-of-flight mass spectrometry (LD/TOF-MS) is evaluated for the determination of stable metal isotope ratios. The isotope ratios of five metal ions (Cu, Ca, Mg, Fe, Zn) in atomic absorption standard solutions and two metal ions (Ca, Mg) in human serum samples are determined. With an existing LD/TOF-MS instrument we show that the technique can overcome the difficulties of the most commonly used methods for measuring metal isotope ratios: (1) all metals are ionizable without surface treatment, thus overcoming the major drawback of thermal ionization mass spectrometry (TIMS); (2) there is no matrix involved to interfere with the metal ion detection, thus overcoming the major disadvantage of inductively coupled plasma mass spectrometry (ICPMS); (3) there is no interference from hydride ions, a major disadvantage of fast atom bombardment secondary ionization mass spectrometry; (4) a mixture of metals can be detected simultaneously using a single laser wavelength, overcoming the major disadvantage of resonance ionization mass spectrometry; (5) accuracy and precision comparable to ICPMS can be achieved with the current instrumentation; (6) precision comparable to TIMS is feasible; and most importantly (7) high precision can be achieved on very small quantities of material because the LD/TOF-MS instrument permits all masses to be monitored simultaneously and very small differences in isotope ratio can be detected.

Twiddler's syndrome in children: an unusual cause of pacemaker failure

Mechanical causes of pacemaker failure are well recognised. Twiddler's syndrome leading to pacemaker failure has been previously recognised in adults, but there have been no published reports of its occurring in children. Two cases leading to failure of the pacing system are reported. In the first twiddling led to fracture of the lead and in the second it led to displacement of the lead from the heart. Children may be more susceptible to twiddler's syndrome because they have thinner subcutaneous tissues, making leads more accessible, and their comprehension of the consequences may be poor.

The publication of clinical facts: a natural-science view

Authors face a variety of obstacles to publication after submitting their papers to scientific journals. The first of these derives from the meaning of the word 'fact' and the phrase 'clinical fact'. A second arises from the ambiguous nature of the analysing instrument used to accumulate clinical data. A third is a result of the different perspectives used by analysts to inform their observational instruments. The fourth impediment is a cognitive one: there are often serious lapses in logical operations involving predicate identifications and hasty generalisations. The fifth is a result of an awkward contemporary glossary, a glossary that extends ambiguities rather than relieves them. Finally, there is an obstacle that derives from style.

Induction of antitumor immunity by recombinant vaccinia viruses expressing B7-1 or B7-2 costimulatory molecules

Activation of T cells requires at least two signals: an antigen-specific signal delivered through the T-cell receptor and a costimulatory signal mediated through molecules designated B7-1 and B7-2. Previous studies have shown that introduction of B7-1 and B7-2 into tumors using retroviral vectors has led to enhanced antitumor effects. A limiting factor for potential clinical applications using this approach is the low efficiency of infection of retroviral vectors and consequent manipulations of infected cells. Vaccinia virus thus represents an alternative vector for B7 gene expression in tumor cells. In this report we describe the construction and characterization of recombinant vaccinia viruses containing the murine B7-1 and B7-2 genes (designated rV-B7-1 and rV-B7-2). Infection of BSC-1 cells with these constructs results in rapid and efficient cell surface expression of both B7-1 and B7-2 (> 97% of cells at 4 h). Infection of murine carcinoma cells with low multiplicity of infection of wild-type vaccinia virus leads to the death of the host following tumor transplantation. In contrast, inoculation of rV-B7-1- or rV-B7-2-infected tumor cells into immunocompetent animals resulted in no tumor growth. These studies demonstrate the utility of recombinant vaccinia viruses to deliver B7 molecules to tumor cells for potential gene therapy and recombinant approaches to cancer immunotherapy.

Enhanced immune responses and anti-tumor activity by baculovirus recombinant carcinoembryonic antigen (CEA) in mice primed with the recombinant vaccinia CEA

Carcinoembryonic antigen (CEA), a glycosylated protein of Mr 180, is one of the most widely studied oncofetal antigens. A majority of gastrointestinal cancers as well as breast and non-small-cell lung carcinomas express CEA. CEA thus represents a potential target for immunotherapy of several carcinoma types. A recombinant vaccinia-CEA virus (rV-CEA) was previously shown to induce anti-tumor activity in an experimental murine model after three rV-CEA inoculations. However, because the majority of cancer patients have received a previous smallpox vaccination, a long-lasting immune memory and/or induced anamnestic responses against vaccinia proteins may prevent repetitive boosting with the recombinant vaccinia virus expressing CEA. Therefore, other types of vaccines may be required to boost the anti-CEA immune response; one such schema would be the use of purified CEA as a boost in hosts given one administration of rV-CEA. Commercially available sources of CEA are usually derived from liver metastases extracts and are sometimes contaminated with nonspecific cross-reactive antigen. We have previously generated a recombinant source of full-length human CEA using a baculovirus expression system (bV-CEA). bV-CEA was shown to be glycosylated differently than native CEA, but it contains at least 10 epitopes found on native CEA (nCEA). Moreover, bV-CEA was able to induce a humoral response against CEA present on human colorectal cancer cell lines.(ABSTRACT TRUNCATED AT 250 WORDS)

Immune response to a carcinoembryonic antigen polynucleotide vaccine

We have constructed a DNA plasmid encoding the full length complementary DNA for human carcinoembryonic antigen (CEA) driven by the cytomegalovirus early promoter/enhancer (plasmid DNA encoding human CEA) and demonstrated that this plasmid can function as a polynucleotide vaccine. This polynucleotide vaccine induced humoral and/or cellular immune responses specific for human CEA in all 5 immunized mice. Lymphoblastic transformation data with the use of enriched T-cell populations detected the presence of CEA-specific memory T-cells in 3 of 5 mice. Lymphocytes from 2 of 5 mice had interleukin 2/interleukin 4 release in response to CEA. CEA specificity was confirmed by the absence of reactivity to a control antigen and lack of CEA reactivity among mice vaccinated with a control plasmid encoding chloramphenicol acetyltransferase. Four of 5 mice vaccinated with plasmid DNA encoding human CEA demonstrated anti-CEA antibody responses. This immune response compared favorably with a positive control group of mice immunized with vaccinia-CEA by a dose and schedule previously shown to induce immunoprotection and therapy against a human CEA expressing syngeneic murine colon carcinoma model. Studies are ongoing to establish the construct, dose, and schedule to elicit optimal CEA-specific immune response as well as immunoprotection and therapy against human CEA expressing syngeneic murine adenocarcinoma models.

Immunogenicity and safety of a recombinant vaccinia virus vaccine expressing the carcinoembryonic antigen gene in a nonhuman primate

We have previously reported the development of a recombinant vaccinia virus vaccine expressing the human carcinoembryonic antigen (CEA) gene, designated rV(NYC)-CEA. This construct has been shown to elicit specific anti-CEA immune responses and an antitumor effect in a murine tumor model. In the studies reported here, the safety and immunogenicity of this recombinant vaccinia virus were evaluated in a rhesus monkey model. Human CEA is a M(r) 180,000 glycoprotein expressed in approximately 90% of gastrointestinal carcinomas and in some breast and non-small cell lung carcinomas. This family also includes normal cross-reacting antigen (NCA). Rhesus monkeys, like humans, have some NCA on the surface of their granulocytes. Eight monkeys were immunized 3 or 4 times by skin scarification with the recombinant CEA vaccine and four monkeys received wild-type vaccinia virus as control. After three vaccinations, all rV(NYC)-CEA-vaccinated animals exhibited a strong anti-CEA antibody response as measured by enzyme-linked immunosorbent assay. The functional ability of these antibodies to mediate lysis of a CEA-bearing tumor cell was demonstrated using human effector cells. This response could be enhanced by interleukin 2. Cellular immunity to CEA was measured by delayed-type hypersensitivity upon intradermal challenge with purified CEA. Only those animals receiving the recombinant vaccine displayed significant anti-CEA responses. Furthermore, peripheral blood mononuclear cells from immunized monkeys were found to proliferate in response to CEA stimulation. All vaccinated monkeys developed local skin irritation at the site of the vaccination, regional lymphadenopathy, and low-grade fevers after immunization. Following immunization with rV(NYC)-CEA, the response was consistent with the usual constitutional symptoms seen with human smallpox virus immunization. Blood counts, differentials, and hepatic and renal chemistries remained normal in all animals throughout the study and for up to 1 year following the primary vaccination. No evidence of immunological cross-reactivity to NCA was found by either a fall in the granulocyte count or analyses for anti-NCA antibodies. Thus, the rV(NYC)-CEA vaccine appears to be safe in rhesus monkeys. The administration of a CEA recombinant vaccine to rhesus monkeys induces both a humoral and a cell-mediated immune response directed against human CEA.

Antitumor activity and immune responses induced by a recombinant carcinoembryonic antigen-vaccinia virus vaccine

BACKGROUND

Human carcinoembryonic antigen (CEA) is a 180-kd glycoprotein expressed in human colorectal, gastric, pancreatic, breast, and non-small-cell lung carcinomas. Previous studies have demonstrated enhanced immune responses to other antigens presented with vaccinia virus proteins via a recombinant vaccinia virus construct. In addition, we have developed a recombinant CEA-vaccinia virus construct, designated rV(WR)-CEA, and have demonstrated humoral anti-CEA responses in mice after immunization with that virus.

PURPOSE

The goals of this study were (a) to construct a recombinant CEA-vaccinia vaccine in a less virulent vaccinia strain that is potentially safe and effective for treatment of patients whose tumors express CEA and (b) to evaluate the ability of the recombinant CEA-vaccinia vaccine to prevent and reverse tumor growth in mice and to elicit cell-mediated and humoral anti-CEA immune responses.

METHODS

Using the New York City strain of vaccinia virus, which is used in smallpox vaccination and is more attenuated for humans than rV(WR), we derived a recombinant CEA-vaccinia construct, designated rV(NYC)-CEA. The ability of this construct to induce antitumor immunity was evaluated in mice receiving subcutaneous injections of murine colon adenocarcinoma cells expressing the human CEA gene.

RESULTS

Administration of rV(NYC)-CEA in mice induced strong anti-CEA antibody responses, as well as CEA-specific cell-mediated responses, including delayed-type hypersensitivity, lymphoproliferative, and cytotoxic responses. Vaccination of mice with the rV(NYC)-CEA rendered them resistant to the growth of subsequently transplanted CEA-expressing tumors. Moreover, when mice were vaccinated 7 days after tumor cell injection, tumor growth was either greatly reduced or eliminated. No toxic effects were observed in any of the mice.

CONCLUSION

These studies demonstrate that antitumor activity can be induced with the use of a recombinant CEA-vaccinia virus construct derived from an attenuated vaccinia strain, and they reveal the range of cell-mediated and humoral responses induced by this recombinant vaccine.

Confronting dilemmas in the study of character

Distinctive dilemmas in the psychoanalytic study of character are described. What they are and how they have been addressed illuminate the past achievements and some of the future directions of clinical research.

Culture conditions for induction of green plants from barley microspores by anther culture methods

With barley a large variation in frequency of plant formation from microspores of spikes from the same plant has been observed. The highest frequency of plant formation was obtained when culturing anthers in the dark on a high Ficoll medium containing 2,4-D and kinetin to induce proembryo (or callus) formation. Subsequently the proembryos or calli were cultured in dim light on a high Ficoll-high sugar medium containing IBA and kinetin. Finally the embryos were transferred to a starch agar medium. A maximum of 13 green plants were obtained from microspores of a single anther.The ratios of green to albino microspore derived plants varied from 9∶1 to 1∶9 depending on culture conditions. Under anaerobic conditions, lactic acid and other organic acids may have damaged the organelles in the cells resulting in the formation of albino plants. Thus, direct embryogenesis by using a well-buffered, high Ficoll-high sugar medium and proper aeration are essential for obtaining high frequency of green plants from microspores.

The psychoanalytic process: the developmental and the integrative

Psychoanalysis is a treatment that focuses on intrapsychic events and activates integrative tendencies to promote-insights. Almost from the time it originated, however, it was also promoted as a therapy informed by the interpersonal, inducing change through experiences generated within the psychoanalytic situation. In recent years the interpersonal or object relations approach has come to be categorized as "developmental," a term that fosters no end of ambiguities. The resulting confusion compromises the study of the actual developmental process on the one hand and the structure-enhancing features of transactions on the other. This encumbers research on the psychoanalytic process. The author distinguishes the intrapsychic from the interpersonal, the integrative from the developmental, and the two very different realms of psychological activities currently advanced as "developmental."

Orienting perspectives on shame and self-esteem

The orienting perspectives for examining shame and self-esteem included phenomenological, developmental (from a linear and from a discontinuous point of view), pathogenesis, and modes of therapeutic action. The perspectives are overlapping but potential incompatibilities exist, especially in the area of therapeutic action.

The struggle to be thin: a survey of anorexic and bulimic symptoms in a non-referred adolescent population

Ninety-one per cent of a county-wide high school population (N = 5596) completed the Eating Symptoms Inventory (ESI) and the Eating Attitudes Test (EAT). Being female, older and heavier are far more strongly associated with anorexic and bulimic symptoms than is social class. ESI approximations of the DSM-III criteria for anorexia nervosa or bulimia suggest that while both conditions are rare (less than 1%), bulimia is the more prevalent disorder.

Therapeutic processes. A longitudinal view

1. Psychic equilibrium serves work, love, and play. 2. When such equilibrium is disrupted, symptoms occur. 3. Psychotherapy is effective when the equilibrium is restored. The restoration of such equilibrium may be a unifying feature of many psychotherapies. 4. The actions undertaken to restore the equilibrium may be viewed within an operational framework or an intrapsychic one. 5. The operational framework is more readily inferred from observable features. It describes the relationship the patient and doctor make with one another in pursuit of their avowed aims. It highlights technical features. 6. The intrapsychic framework attempts to describe and explain what goes on in the mind of the patient as the treatment proceeds, and what goes on is often very different from the avowed aims of either participant. It highlights individual structure, organization, and meanings. 7. There may be a class of patients who very easily restore their psychic equilibrium within a therapeutic setting, independent of the theoretical assumptions of the therapist or the avowed goals of the treatment. They are people with compelling synthesizing, integrative, and organizing capacities used in the service of development, mastery, and control. There may also be a class of therapists with similar capacities who apply them in conjunction with their authority in order to facilitate such a restoration. The restoration of stability is a valuable treatment goal for many children and adults. 8. Attention to these capacities may be useful for furthering clinical work and for appraising various theories of therapeutic action, especially those theories that rely heavily on positive clinical results for evidence. It may also be one of the starting points to distinguish the treatment process in analysis from the treatment process in other therapies.

Treatment of cytomegalovirus pneumonia

In a multicenter uncontrolled trial of ganciclovir therapy for well-documented cytomegalovirus (CMV) pneumonia in 21 patients following bone marrow transplantation, eight (38%) of 21 survived for more than 90 days. Two additional patients responded to ganciclovir therapy; one survived for 60 days before relapsing with fatal CMV pneumonia, and the other survived 79 days before dying with disseminated aspergillosis. No CMV disease was found in this latter patient at autopsy. The improved survival of patients in this trial may be due to a small number of patients (23%) who developed significant neutropenia during ganciclovir therapy, to the concurrent use of CMV immune globulin in three of the survivors, or to other variables affecting a positive outcome. Data on the use of CMV DNA-DNA hybridization assays to detect CMV DNA directly in patients' blood suggest that this method may be useful in following the clearance of CMV viremia in patients receiving ganciclovir. The results of treatment of CMV pneumonia in bone marrow transplant recipients are compared with those of previous studies, of CMV pneumonia in renal transplant recipients, and of CMV pneumonia in patients with AIDS. Suggestions for further, more definitive, studies of CMV pneumonia are presented.

The massacre of MASSCARE. Dukakis' health-insurance plan and why it was defeated

The authors critique the health-insurance plan proposed by Governor Michael Dukakis, and recount the uproar that followed its introduction into the Massachusetts legislature this past fall. With Dukakis having emerged as a leading contender for the Democratic presidential nomination, and with much hope for fundamental reform of our nation's health-care system hinging on the outcome of this year's elections, the plan, and its fate, may well provide a taste of things to come.

They did it in Massachusetts. A report on the first national health referendum

"Shall the Commonwealth of Massachusetts urge the United States Congress to enact a national health program which: provides high quality comprehensive personal health care including preventive, curative and occupational health services; is universal in coverage, community controlled, rationally organized, equitable financed, with no out-of-pocket charges, is sensitive to the articular health needs of all, and is efficient in containing its cost; and whose yearly expenditure does not exceed the proportion of the Gross National Product spent on health care in the immediately preceding fiscal year?"